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I APPLICATIQN FOR PERMIT , SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l f (Complete in Triplicate) t to constf�ct. rk herein .This application is k Application is honey made nothe Joa u n County ordinain lnce No.549 for sewage or-Health District for a N6. 1662 for weilldpump or install nd the Rules and Regulations of the San Joaquin Joaqui made in compliance with San q -Local Health District. t' f City Lot Size / PM Job Address r� Phone Owner's Owner's Name `' r �lilMhf Address f1 .,;, �✓ ! License No. \vw Contractor P�--Address _ I `',_WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ PUMP INSTALLATION ❑ �::'.—`SYSTEM REPAIR ❑ 4 „_ - DISPOSAL FLD. PROP. LINE 1 ` SEWER LINES AN pITSISUMPS DISTANCE TO NEAREST: SEPTIC TK AGRICULTURE WELL OTHER WELL FOUNDATION ` TYPE OF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS INTENDED USE Dia. of well Casing 0 Open Bottom ❑ Man'teca Dia. of Well Excavation ,. Ll Industrial r Type of Casing "~ Specifications ❑ Domestic/Private 11 Gravel Pack 017racy ` ❑ Other t f❑ Delta Depth of Grout Seal `"�- Type of Grout M Public Suria a Seal installed by ` �,Approx. Depth I I Eastern{ �- I I Irrigation , i State Work Done " .P. H Repair Work Done ❑ Type of Pump .,,.—�=,� 1� a 1r �, •;.� �^ _ Sealing Material (top 50') Well Destruction ❑ Well Diameter,,_ [ Depth i Filler Material )Below 50'1 per i f TYPE OF SEPTIC WORK: NEW INS TALLATION i RE iRlADDITION l i DESTRUCTION I I ( o se tic thin 2�0 feet'tled pubic sewer is. �.. ^ \ Installation will serve: Residence_ Comm Other ciaf�,�� Number of living units: r Number of bedrooms,—k� Water table depth~� Character of soil to a deo-pth 9'3 feet: Capacity_�v—�z .- No. Compartments r i SEPTIC TANK Type/Mfg Method of Dispos4' PKG, TREATMENT PLT. © .. +;:.:, Property Line 3 - Distance to,nearest: Well Foundation A P Y Tota length/size LEACHING LINELNo. & Length of lines. F Property Line Ll to nearest:. ";Wel FILTER BED l Foundation 4I Size ' J Number I SEEPAGE PITS { I Depth Property Line , SUMPS Ll Distance to nearest: Wel{ `Foundation y DISPOSAL PONDS ❑ f . I hereby certify that l have prepared this application and.that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify,that in the'performance of the work for which this permit is issued, I signature shall not employ any person in such manner as to become"sublecYto workman's compensation laws of California." Contractor's ns+ring or sub sub'subject to workman's-contracting the following: "I certify that in the performanc jof the work for which this permit is issued, I shall employ p 1 1 tion laws of California." s r The applicant must c all req 'ed Inspections. complete drawing on reverse sid�/aI G 9 Signed X Title: Date: O # R DEPARTMENT USE ONLY � Date Area Application Accepted by Pit or Grout Inspection by Date +-, _ Final Inspection by Date 1 Additional Comments: C1 Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 } Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 } CK RECEIVED BY DATE PERMIT'N0. a FEE ,AMOUNT DUE AMOUNT REMITTED CASH f� .f INFO k + EH 13-24IREV.+/Hsi -.,...- EH 14-28 - „ oM4r• � -_..